Patients who lose all or part of their esophagus must rely on a feeding tube implanted into the abdomen for nourishment—a tube that can lead to infection, social isolation and even undernourishment. Many of these patients are candidates for esophageal reconstruction, which uses tissue from one part of the body to replace the absent esophagus, thereby repairing the conduit from the throat to the stomach and giving patients the ability to eat and swallow again.
Historically, gastric pull-up and colonic interposition have served as the primary reconstructive choices in the face of major esophageal defects. But some patients are not candidates for these surgical approaches because their stomach or colon is unavailable or unsuitable. Others who undergo traditional esophageal transplant suffer post-surgical complications such as loss of blood supply to the transplanted tissue and leakage due to poorly healing connections.
In all of these cases, the small intestine serves as a reliable alternative for the reconstruction of total esophageal defects, says Gordon Lee, MD, director of microsurgery in the division of plastic and reconstructive surgery. The small intestine has several qualities that make it a suitable, even preferable, alternative for reconstructing the esophagus. It is a relatively disease free segment of the bowel, it closely resembles the diameter of the esophagus and it mimics the muscle flexibility of the throat, and thereby may improve functionality and decrease postoperative reflux.
"Total esophageal reconstruction using the small intestine is a difficult procedure," Lee says. That's why he teams up with oncologic and thoracic surgeons on every procedure. Lee performs the majority of cases with Jeffrey Norton, MD, chief of surgical oncology, and Joseph Shrager, MD, chief of thoracic surgery, but also does some with George Poultsides, MD, assistant professor of surgery and Robert Merritt, MD, assistant professor of cardiothoracic surgery. The surgery requires a match of size, blood supply and tissue quality that will support the passage of food and avoid the leakage and tissue death that can mark other choices of transplanted tissue. "We use the small intestine, which is a much better size match, and we use microsurgery to augment the blood supply," Lee adds.
And with that approach, Stanford has been getting excellent results. "All of our patients initially came to us unable to eat, drink or even swallow sometimes for months, even years, as a result of cancer or surgery," he says. "And all of the patients we've done have resumed a normal, regular diet and are maintaining their weight." To learn more about recovery from esophageal repair, read about Stanford patient Gilbert Hudson.
Stanford's team sees a number of patients whose first attempts at esophageal transplant have failed, many because of poor blood supply to the transplanted tissue. To combat this complication, the team uses a technique to monitor the blood supply of the newly transplanted tissue. During surgery, the team leaves a small piece of the intestine outside the body, but ensures that it is connected to the same blood supply as the transplanted tissue inside the esophagus. This allows them to see how well the tissue inside the body is responding to its new home. Once they know that the blood vessels are secure and doing well, they can remove the external flap of tissue right at the bedside. "It's a very tricky way to ensure that there's good circulation deep down inside," says Lee.
"If you have a patient who has failed some of the more traditional surgeries of pulling up the stomach or pulling up the colon, this is another option for them," he adds. In fact at Stanford, use of the small intestine is fast becoming the primary way of replacing esophageal tissue in appropriately selected patients.
By Grace Hammerstrom